Part of a series. Here is a model for the delivery of primary care which offers certain rights balanced by responsibilities for patient, provider and insurer alike. First the rights of each party. As a patient, you deserve a high level of care in a satisfying manner without frustrations. The insurer and your employer want to see the total cost of health care come down. The physician wants the satisfaction ...

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5 a.m. on a Friday morning, during a lull in my overnight shift, I got a text from my friend Julie (name changed). “Steve had a massive heart attack.” Me back: “OMG, what happened.” Julie: “Not sure, he called my mom, he thought he was going to die. Now they are doing a CT scan.” And so it went on. As I waded through the information, Julie thought she understood I realized that she ...

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Three (and a half) years ago, when I left my old practice, I was near burnout.  I was exhausted, not because of the amount of time I was spending -- it was actually about the same, if not less than I had worked before -- but because of an ever-increasing gulf between me and my patients.  I have always tried to give care that focused on the person with me ...

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Science, to use the term correctly, isn’t a body of knowledge or a bunch of facts written up on a whiteboard by a crazy-haired professor. It’s a method, or way of figuring out things. Thinking and reading and learning from experts are all important, sure. But real science relies on experimentation. First, make an educated guess about how something works. Then design an experiment to test your guess. (I’m oversimplifying here. ...

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Over the last several years since I graduated from residency, I’ve worked in many different hospitals up and down the east coast. These have ranged from large urban medical centers to rural community outposts. In all of these places I’ve felt the inevitable conflict that exists between physicians and administrators -- to varying degrees. It almost seems like a rite of passage that the world of clinical medicine and administration are ...

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You have a persistent cough and poor appetite, but for six months your doctor has prescribed an assortment of antibiotics after an initial chest x-ray showed a small pneumonia. Finally, short of breath, you go to the emergency room where a CT scan reveals untreatable lung cancer. Later you find your doctor has received a bonus from your HMO insurer for not ordering a CT scan earlier. Physicians count on experience ...

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Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental and lies at the root of today’s epidemic of physician burnout. Historically, there have been three learned professions: law, medicine, and theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others. Learned professionals have, over many centuries, worked ...

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Hope is a tricky thing. On the one hand, false hope can lead patients to opt for painful, futile treatments at the end of life. On the other, unnecessarily bleak outlooks can lead to depression and inaction. When health is at stake, presenting information with the right amount of hope can guide patients away from both suffering needlessly and/or succumbing to treatable disease. I was reading a sad story ...

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A nudge is a form of social engineering to make better choices. In the world of patient safety and medical decisions, it shares some of the concepts of  human factors engineering. Richard Thaler and Cass Sustein may be the world’s authority on the nudge concept, and have a great book by the same name. Nudges help people to choose their own best decisions by making the easiest, laziest choices -- the defaults -- ...

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It is exactly 49 steps from my bedroom to my garage.  It is a 23-mile drive to the hospital and 75 steps to the unit.  It takes 10 seconds to walk to the nursing station.  I can measure what it takes to get me to work each morning with absolute certainty.  I know because I have measured it a million times hoping something will prevent me from reaching my destination.  ...

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